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Severe aortic stenosis (AS) and mitral regurgitation (MR) frequently coexist. Although some observational studies have reported that moderate or severe MR is associated with higher mortality, the optimal management of such patients is still unclear. Simultaneous replacement of both aortic and mitral valves is linked to significantly higher morbidity and mortality. Recent advances in minimally invasive surgical or transcatheter therapies for MR allow for staged procedures in which surgical or transcatheter aortic valve replacement (SAVR/TAVR) is done first and MR severity re-evaluated afterwards. Current evidence suggests MR severity improves in some patients after SAVR or TAVR, depending on several factors (MR aetiology, type of valve used for TAVR, presence/absence of atrial fibrillation, residual aortic regurgitation, etc). However, as of today, the absence of randomised clinical trials does not allow for evidence-based recommendations about whether or not MR should be addressed at the time of SAVR or TAVR. A careful patient evaluation and clinical judgement are recommended to distinguish patients who might benefit from a double valve intervention from those in which MR should be left alone. The aim of this review is to report and critique the available data on this subject in order to help guide the clinical decision making in this challenging subset of patients. [ABSTRACT FROM AUTHOR]

Objectives: Rheumatic mitral stenosis (MS) is a progressive disease, and risk of death may persist despite relief of the obstruction. Net atrioventricular compliance (Cn) modulates the overall haemodynamic burden of the MS and may be useful in predicting cardiovascular death after percutaneous mitral valvuloplasty (PMV).Methods: A total of 427 patients (mean age 50±16 years, 84% female) with severe MS undergoing PMV were enrolled. Doppler-derived Cn was estimated at baseline using a previously validated equation. The primary endpoint was late cardiovascular death, and the secondary endpoint was a composite of all-cause mortality, mitral valve (MV) replacement or repeat PMV over a median follow-up of 31 months (IQR: 7.8-49.2 months).Results: At baseline, 209 patients (49%) were in New York Heart Association (NYHA) functional class III or IV. During follow-up, 49 patients died (41 cardiovascular deaths), 50 underwent MV replacement and 12 required repeat PMV, with an overall incidence of cardiac mortality and adverse events of 4.1 deaths and 11.1 events per 100 patient-years, respectively. Low baseline Cn was a strong predictor of both cardiac death (adjusted HR 0.70, 95% CI 0.49 to 0.86) and composite endpoint (adjusted HR 0.81, 95% CI 0.67 to 0.91) after adjusting for clinical factors, baseline pulmonary artery pressure, tricuspid regurgitation severity, right ventricular function and immediate procedural haemodynamic data. The inclusion of Cn in a model with conventional parameters resulted in improvement in 5-year cardiovascular mortality risk prediction.Conclusions: Baseline Cn is a strong predictor of cardiovascular death in patients with MS undergoing PMV, independent of other prognostic markers of decreased survival in MS, including baseline patient characteristics and postprocedural data. Cn assessment therefore has potential value in evaluation of cardiovascular mortality risk in the setting of MS. [ABSTRACT FROM AUTHOR]

Mitral valve repair (MVRepair) has become the procedure of choice to correct severe degenerative mitral regurgitation (MR), due to its documented superiority to valve replacement regarding long-term survival, freedom from valve-related adverse events and preservation of left ventricular (LV) function. The refinement of MVRepair techniques has rendered almost all valves (more than 95%) amenable to repair with a 15-year freedom from reoperation of 90%. The concept of 'centres of excellence for MVRepair' has emerged, encouraging referring doctors to select the most experienced institutions or individual surgeons to deal with the most complex cases, based on repair volume, appropriate peri-procedural imaging and data regarding expected outcomes (repair, mortality and durability of repair). Based on the good results, operating on asymptomatic patients with severe MR is now widely accepted, prophylactically avoiding the dire consequences of chronic MR, such as LV function deterioration/enlargement, and development of atrial fibrillation and pulmonary hypertension. In reference centres, where the repair rate is over 95% for all types of disease with <1% mortality, it has become standard practice in nearly 50%-60% of all patients submitted to MVRepair. Finally, recent advances in the surgical treatment with the purpose of reducing invasiveness and surgical trauma, through partial sternotomy or mini-thoracotomy (video-assisted with or without robotics), are now being increasingly performed in 20%-30% of centres, claiming comparable results to conventional surgery. In addition, transcatheter technology, particularly the MitraClip, is evolving and treading its way in the treatment of high-risk patients with severe MR, but the results are still short of ideal. [ABSTRACT FROM AUTHOR]

Objective: As the efficacy of surgical ablation for atrial fibrillation (AF) is reported to be suboptimal for patients with a giant left atrium (LA), its routine use on this population has remained controversial. We sought to evaluate the clinical outcomes of patients with a giant LA undergoing mitral valve (MV) surgery with/without the maze procedure.Methods: We identified 759 patients with a giant LA (>60 mm) and AF undergoing MV surgery from 1999 through 2012. Of these, 400 underwent MV surgery with the maze procedure (maze group), and the remainder (n=359) underwent MV surgery only (no-maze group). To reduce the impact of selection bias, propensity score analyses were performed based on 25 baseline covariates.Results: Early death occurred in five (1.3%) and nine (2.5%) patients in the maze and the no-maze group, respectively (p=0.28). Freedom from AF at 5 years was 68.9% in the maze group and 9.6% in the no-maze group (p<0.001). After adjustment, the maze group showed a significantly lower risk of death (HR, 0.65; 95% CI 0.44 to 0.98; p=0.038), thromboembolic events (HR, 0.23; 95% CI 0.09 to 0.58; p=0.002) and composite adverse outcomes (death, congestive heart failure and valve-related complications; HR, 0.55; 95% CI 0.42 to 0.71; p<0.001) than the no-maze group. In subgroup analyses, MV surgery with the maze procedure resulted in higher survival and event-free survival in most risk subgroups than without the maze procedure.Conclusions: The concomitant maze procedure improved postoperative rhythm status, clinical outcomes and cardiac functions in patients with a giant LA undergoing MV surgery. This study indicates that the patients with a giant LA undergoing MV surgery may benefit from an addition of the maze procedure. [ABSTRACT FROM AUTHOR]

Objectives Cleft-like indentations (CLI) are deep separations between scallops of the mitral posterior leaflet observed in myxomatous mitral valve disease (MMVD), but their diagnosis, mechanisms and implications are unknown. Using 3D transoesophageal echocardiography (3DTOC), we aimed at assessing diagnostic accuracy and defining mechanisms of CLI in patients undergoing surgery for MMVD. Methods 3DTOC of mitral valve was acquired in 49 patients with MMVD and severe regurgitation prior to valve repair. Qualitative review compared 3DTOC diagnosis of CLI with surgical inspection. Mitral, annular and leaflet dimensions were quantified with dedicated software and compared between those with and without CLI. Results Diagnosis of CLI was made by 3DTOC in 17 (35%) while none was identified by 2D and was confirmed in 15 (88%) by surgical inspection. Mechanistically, LV diameters and mitral regurgitant volume (RVol) were similar with and without CLI (p>0.49). Conversely, mitral annulus was smaller with CLI (anteroposterior diameter 42.2±7.1 vs 47.0 ±7.5 mm, p=0.04; circumference 133±16 vs 148 ±19 mm, p=0.009; area 1289±326 vs 1619±427 mm², p=0.008). Prolapse volume tended to be smaller with CLI (1.9±1.2 vs 4.0±4.3 mL, p=0.06) involving single posterior scallop at surgery (82% vs 44%, p=0.007) with smaller 3DTOC leaflet area (1574±409 vs 2019±652 mm², p=0.01). During valve repair, surgical closure of all surgically diagnosed CLI was required. Conclusions Posterior leaflet CLI are frequent in MMVD, are identified by 3DTOC with high accuracy and require closure during valve repair. CLI are mechanistically not related to excess annular enlargement or excess prolapse. Conversely, CLI occur in the context of single scallop prolapse with tissue paucity causing excess separation of scallops. These 3DTOC data enhance diagnostic and mechanistic comprehension of the diversity of MMVD phenotypical presentation. [ABSTRACT FROM AUTHOR]

Objective: Current guidelines recommend that most patients aged ≥65 years should undergo mitral valve replacement (MVR) using a biological prosthesis. The objectives of this study were to assess whether these guidelines are being followed in UK practice, and to investigate whether the guidelines are appropriate based on in-hospital mortality and mid-term survival. Methods: Data from the National Institute for Cardiovascular Outcomes Research Adult Cardiac Surgery Audit database from all National Health Service (NHS) hospitals and some private hospitals performing adult cardiac surgery in the UK between April 2001 and March 2011 were analysed. The overall cohort included 3862 patients aged ≥65 years who underwent first-time MVR. Propensity score matching and regression adjustment were used to compare outcomes between prosthesis groups. Results: The mean age was 73.0 years (SD 4.9) with 50% of patients having surgery with a mechanical prosthesis. This proportion decreased over the study period and with increasing patient age with marked variation between hospitals. In the propensity-matched cohort, in-hospital mortality in the biological group was 6.9%, and in the mechanical group it was 5.9% giving an unadjusted OR of 1.17 (95% CI 0.84 to 1.63). There was no significant difference in mid-term survival between the matched groups with an unadjusted HR for biological prosthesis of 1.08 (95% CI 0.93 to 1.24). Similar results were found when using regression adjustment on unmatched data. Conclusions: Current guidelines concerning age and mitral valve prosthesis choice are not being followed for patients aged ≥65 years. With regards to in-hospital and mid-term mortality, this study demonstrates that there is no difference between prosthesis types. [ABSTRACT FROM AUTHOR]

The article presents a study on the mechanical mitral valve thrombosis in patient with rheumatic valve disease. It cites the case of a woman in her late 30s, who was admitted with a two-week history of shortness of breath and productive cough. It also describes the medical history of the patient and has undergone a transthoracic and transoesophageal echocardiogram. The study reveals that the patient has an increased gradient across the mitral valve that resulted to valve obstruction.

We present a case of a young woman who was initially diagnosed with acute stroke with no obvious risk factors. Preliminary investigation with transthoracic echocardiography and subsequent advanced imaging with transoesophageal echocardiography suggested the diagnosis of a benign cardiac tumour on the anterior leaflet of mitral valve. The patient underwent urgent surgical resection. Histology confirmed the diagnosis of cardiac papillary fibroelastoma. She made complete clinical recovery with no recurrence of symptoms. [ABSTRACT FROM AUTHOR]

Objective To compare mitral valve area (MVA) measurements obtained by 2D transthoracic planimetry and 3D transoesophageal echocardiography (TOE) in patients with mitral stenosis (MS), and to determine the causes of discrepancies between the two techniques. Design Reliability and agreement study. Setting Tertiary referral centre. Patients Eighty-seven patients with MS. Methods MVA was determined by transthoracic 2D planimetry and 3D TOE. Clinical and echocardiographic variables were evaluated. The angle (Ma) between the lines of the true mitral valve (MV) tip and the echo beam-to-MV tip was measured at early diastole from the parasternal long-axis view obtained from 2D echocardiography. Results Although MVA measurements using 2D planimetry and 3D TOE showed good agreement (intraclass correlation coefficient, 0.853; p<0.001), 2D planimetry overestimated MVA by 0.19±0.2 cm2 compared with 3D TOE (p<0.001). Left atrial (LA) dimension obtained from the parasternal long-axis view at end-systole (p=0.012), Ma (p<0.001), and left ventricular ejection fraction ( p=0.022) were independent determinants of the MVA difference (MVA by 2D--MVA by 3D TOE; MVA2D-3D) according to multiple linear regression analysis. The LA dimensions correlated with Ma (r=0.352, p=0.001). The best cut-off values for predicting significant overestimation by 2D planimetry (MVA2D-3D>0.2 cm2) were LA dimension =49 mm (78% sensitivity, 72% specificity) and Ma=9.5° (56% sensitivity, 89% specificity). Conclusions Because 2D planimetry tends to overestimate MVA, 3D TOE should be considered for accurate MVA assessment, especially in patients with a large LA and large Ma. [ABSTRACT FROM AUTHOR]

The article provides information on the anatomy, haemodynamics, mechanisms, echocardiographic assessment, and outcome of secondary mitral regurgitation (MR). The mitral valve apparatus is comprised of the mitral leaflets, the mitral annulus, the papillary muscles, the chordae tendinae, the left ventricle (LV), and the left arterial walls. The complexity of the physiopathology of secondary MR is explained. The treatment approaches for MR are also discussed.

Objective To assess the severity of the disease and the long-term cardiac prognosis for neonates who developed enterovirus (EV) myocarditis within the first weeks of life. Design Clinical presentation, echocardiographic and ECG findings and the outcome of seven infants with EV myocarditis admitted to the intensive care unit are reported. Additionally, 28 previously reported cases are described. Results Seven neonates presented with cardiac failure within 17 days after birth requiring respiratory and circulatory support. Echocardiography showed dilatation and severe dysfunction of the left ventricle in all and mitral regurgitation in six. In six patients the echocardiographic pattern resembled myocardial infarction. ECG showed complete loss of the R-wave and a new Q-wave in the left precordial leads in all. Two infants died and five developed long-term cardiac sequelae requiring medication. In all survivors aneurysm formation in the left ventricular wall was found weeks to months later. One patient is awaiting heart transplantation. Coxsackie virus B was detected in blood, cerebrospinal fluid, nasopharyngeal swab or stool by PCR or culture. The mortality of previously described neonates combined with our seven cases was 31% (11/35). Among the survivors 66% (16/24) developed severe cardiac damage. Only 23% (8/35) of the infants fully recovered. Conclusions EV myocarditis is a rare but severe disease in the neonatal period, which often leads to death or results in serious chronic cardiac sequelae like chronic heart failure, aneurysm formation within the left ventricle and mitral regurgitation. Chronic cardiac drug therapy is necessary in the majority of these patients. [ABSTRACT FROM AUTHOR]

Background Functional mitral regurgitation (FMR) may occur in patients with reduced or preserved left ventricular ejection fraction (LVEF) and has been associated with excess valvular tenting only in patients with reduced LVEF. This study aimed at identifying the predictors of FMR and to determine whether or not they are different in patients with reduced versus preserved LVEF. Methods 190 consecutive patients free of congenital or primary valvular disease had a comprehensive echocardiographic assessment of LV remodelling and function, diastolic function and FMR severity. Results 112 patients had depressed LVEF (<50%) and 78 had preserved LVEF. FMR was present in 30 patients with preserved LVEF and in 65 with reduced LVEF. Higher E/Ea, E/A and larger mitral tenting were independent predictors of FMR regardless of LVEF. The mitral tenting area was an independent predictor of FMR severity in patients with reduced or preserved LVEF (p=0.04 and p=0.0045) in addition to E/A (p=0.0007), E/Ea (p=0.004) in patients with reduced and preserved LVEF, respectively. Higher E/Ea was independently associated with larger mitral tenting in patients with reduced and preserved LVEF. Mitral tenting area was linearly related to E/Ea (r=0.30, p<0.0001) and E/A (r=0.43, p<0.0001) and LA enlargement (r=0.54, p<0.0001) after having paired 96 patients with and without FMR on indices of LV remodelling. Conclusions In both patients with preserved and reduced LVEF, mitral tenting that leads to FMR is mainly determined by both mitral tethering forces—that is, displacement of papillary muscles and by pushing forces—that is, increased left atrial pressure. This study underscores that LV preload is a key determinant of FMR. [ABSTRACT FROM AUTHOR]

Papillary fibroelastomas (PFEs) are benign cardiac tumours that typically arise on diseased aortic or mitral valves. Usually solitary, PFEs are characterised by numerous frond-like branches attached to the valve surface by a single stalk, elastic tissue present within the central core, and the appearance of a sea anemone when immersed in water. PFEs have a predilection for men with a mean age of 56 years. A very rare case of a 25-year-old man with multiple lesions on the aortic and mitral valves and a large confluent "carpet-like" lesion in the left ventricular cavity is presented. Admitted with a significant left middle cerebral artery stroke and hemiplegia, investigations showed a left ventricular outflow tract lesion, with surgical excision displaying a multifocal "carpet-like" PFE. Histopathological examination showed various lesions presenting with a short stem, several fronds arising from each stem like a "tree trunk", and elastic tissue within the central core. This case is presented, along with a review of 833 reported cases of PFEs published after the year 2001. It is believed that this is the first reported instance of surgically resected and morphologically confirmed multiple PFEs seen and removed at one operation. [ABSTRACT FROM AUTHOR]

The article provides information on Ischaemic mitral regurgitation (MR). It states that MR refers to the changes of left ventricular structure, however, the acute manifestation of MR after infarction is referred to rupture or stretching of the papillary muscle. It notes that ischaemic MR's frequency differs based on the used technique for its detection, management of the patients, and timing post-myocardial infarction (MI).

Background: CAT causes reduction in MA due to left ventricular (LV) remodelling, but determinants of clinically meaningful MR reduction acutely after CAT have not been evaluated. Objectives: We evaluated echocardiographic predictors of significant reduction in functional mitral regurgitation (MA) by cardiac resynchronisation treatment (CAT). Methods: 35 patients with ⩾ moderate to severe MA underwent CAT for presence of electrical and/or mechanical dyssynchrony. Significant reduction in MA post-CAT was defined as reduction to less than moderate MA (MA jet area/left atrial area <25%, group 1) on follow-up echocardiogram at 1.7 (SD 2.8) months post- CAT. Results: Significant MA reduction of 62% (28%) from baseline MA occurred in 18 patients vs 22% (16%) in the remaining patients (group 2), p<0.0l(. Follow-up left ventricular ejection fraction (LVEF( was 0.43 (0.09) in group 1 patients vs 0.29% (0.1%) in group 2 patients (p<0.001(. On multivariate analysis, time to peak strain in the mid inferior segment was the only significant predictor of MA reduction post-CAT (p = 0.008, OA = 1.023 (Cl 1.006 to 1.041). The sensitivity and specificity of the combined variable of time to peak strain of >400 ms in the mid inferior segment and peak negative strain of ⩾9% and 8% in the basal and mid posterior segments, respectively, to predict follow-up MA was 88% and 93% respectively and positive and negative predictive value was 94% and 87%. Conclusion: In patients with cardiomyopathy and significant MA, the presence of delayed longitudinal strain in the mid inferior LV segment along with preserved negative systolic strain in the basal and mid posterior segments predicts substantial reduction in MR post-CRT. [ABSTRACT FROM AUTHOR]

The article reports on different clinical entities of Ischemic mitral regurgitation (IMR) which is commonly caused by ischemic heart disease. The different clinical entities which affect the clinical decision making are the acute IMR complicating an acute myocardial infarction, true IMR secondary to a transient ischemic phenomenon, and the chronic functional IMR (FIMR).

Management of tricuspid regurgitation (TR) is becoming an increasingly difficult decision-making problem. TR occurs in 8–35% of patients, especially in association with acquired left heart valve disease of rheumatic origin, primary isolated TR being very rare. It is more frequently found in association with mitral rather than with aortic valve disease, and is much rarer in degenerative disease. In the majority of patients (70–85%), the TR is said to be ‘functional’, caused by dilatation of the annulus as a result of increased pulmonary and right ventricular pressure; in the remaining 15–30% of the cases it may be organic and related to direct involvement of the tricuspid valve by the rheumatic disease. Whichever type, TR has a significant impact on the clinical condition and the medium and long-term prognosis of the patients. Hence, it requires special consideration during mitral and/or aortic valve surgery and thereafter. In 1967, Brawnwald et al advised a conservative (no touch) approach to TR. Indeed, it was thought that appropriate correction of the left-sided valve disease would most probably result in a decrease or even abolition of the so-called functional TR. However, experience has shown that TR does not always disappear, and may increase, especially when the mitral and/or aortic valve disease is not completely or adequately resolved during surgery, as happens sometimes in cases with less than perfect correction of mitral regurgitation or stenosis. Furthermore, isolated severe TR is now increasingly observed in patients with normal left heart valve function after either mitral valve annuloplasty or replacement. The true incidence of secondary TR is not well known, but it has led some to question the functional nature of TR, accompanying left-sided valve disease. Even moderate TR observed during surgery of left heart valves may not regress spontaneously, especially when there is already a degree of right ventricular dysfunction indicated by annular dilatation. In their experience with patients who were subjected to valvuloplasty for mitral valve regurgitation, Dreyfus et al found that the tricuspid annulus was abnormally dilated in about 50% of the patients, even in the absence of TR. [ABSTRACT FROM AUTHOR]

Objectives: To describe the incidence and rate of dilatation of the ascending aorta in children with bicuspid aortic valve (BAV) and to determine factors that predict rapid aortic dilatation. Design: Retrospective cohort study. Setting: Regional tertiary care children's hospital. Patients: All children aged 0-18 years seen at the authors' institution between 1990 and 2003 with an "isolated" BAV. All patients had had more than one technically adequate echocardiogram, at least six months apart, with concomitant height and weight data. Interventions: Offline echocardiographic measurements of multiple levels of the aortic root were completed for each participant at each serial echocardiogram. These measurements were then compared with expected measurements derived from a normal local control population. Main outcome measures: Rate of change of the ascending aorta size over time, where aortic size is expressed as the number of standard deviations above or below the mean size expected for a given body surface area (z score). Results: 279 echocardiograms spanning a period of from 9 months to 13.3 years were analysed for 88 patients with BAV. The ascending aorta in the BAV group was larger than expected for body surface area at diagnosis and continued to increase in relative size at each of the four subsequent follow-up echocardiograms. Ascending aortic z score increased at an average rate of 0.4/year. A faster rate of increase in z score was predicted by both larger initial aortic valve gradient and non-use of 3 blockers. Conclusions: Children with BAY are at risk of having a dilated ascending aorta. This risk increases with longer follow up. [ABSTRACT FROM AUTHOR]

From Cutler's first attempt to treat the mitral valve by inserting a tenotomy knife through the left ventricle, to Carpentier's introduction of several repair techniques and a functional classification for assessing mitral valve lesions, the history of mitral valve treatment is exciting. Mitral diseases may be degenerative, ischaemic, infective or rheumatic, with or without superimposed impaired left ventricular function and calcification. Understanding the underlying pathological features is also important in determining whether mitral valve repair is feasible, how the valve should be repaired and the prospect for long-term durability of the repair. Recent advances in minimally invasive mitral valve surgery are promising but more effort is needed to ensure timely mitral valve repair. [ABSTRACT FROM AUTHOR]

The article discusses the heart disorder of improper closure of valves pump out that allows the blood to leak backward. The author relates that this phenomena is common for men than women in their fourth to six decade of life. He added that this disease can be associated with rheumatic heart and most common to the developing countries.

Objectives: To define best practice standards for mitral valve repair surgery. Design: Development of standards for process and outcome by consensus. Setting: Multidisciplinary panel of surgeons, anaesthetists, and cardiologists with interests and expertise in caring for patients with severe mitral regurgitation. Main outcome measures: Standards for best practice were defined including the full spectrum of multidisciplinary aspects of care. Results: 19 criteria for best practice were defined including recommendations on surgical training, intraoperative transoesophageal echocardiography, surgery for atrial fibrillation, audit, and cardiology and imaging issues. Conclusions: Standards for best practice in mitral valve repair were defined by multidisciplinary consensus. This study gives centres undertaking mitral valve repair an opportunity to benchmark their care against agreed standards that are challenging but achievable. Working towards these standards should act as a stimulus towards improvements in care. [ABSTRACT FROM AUTHOR]

The article focuses on the significant application of mitral valve repair (MVR) as a method of choice for surgical correction of mitral regurgitation. Significantly, the author assesses the application of MVR as an accepted alternative to prosthetic replacement. The anatomy and physiology of the mitral valve is presented. The author discusses several methods and techniques of MVR. Finally, the results in other types of pathology are less favorable but for the most part superior to valve replacement and assessment on functional mitral regurgitation and rheumatic mitral regurgitation.

Objective: To evaluate the ability of colour Doppler transoesophageal echocardiography (TOE) to assess quantitatively prosthetic mitral valve insufficiency.Methods: 47 patients were studied with multiplane TOE and cardiac catheterisation. Proximal jet diameter was measured as the largest diameter of the vena contracta. Regurgitant area was measured by planimetry of the largest turbulent jet during systole. Flow convergence zone was considered to be present when a localised area of increased systolic velocities was apparent on the left ventricular side of the valve prosthesis. Pulmonary vein flow velocity was measured at peak systole and diastole.Results: Mean (SD) proximal jet diameter was 0.63 (0.16) cm, with good correlation with angiographic grades (r = 0.83). Mean (SD) maximum colour jet area was 7.9 (2.5) cm2 (r = 0.69) with worse correlation if a single imaging plane was used for measurements (r = 0.62). The ratio of systolic to diastolic peak pulmonary flow velocity averaged 0.7 (1.3) cm (r = -0.66) with better correlation (r = -0.71) if patients with atrial fibrillation were excluded. Mean (SD) regurgitant flow rate was 168 (135) ml/s and regurgitant orifice area was 0.56 (0.43) cm2, with good correlation with angiography (r = 0.77 and r = 0.78, respectively).Conclusions: TOE correctly identified angiographically severe prosthetic mitral regurgitation, mainly by the assessment of the flow convergence region and the proximal diameter of the regurgitant jet. [ABSTRACT FROM AUTHOR]

Objective: To examine the hypothesis that major extracellular matrix (ECM) proteins are expressed differently in the left atrial tissue of patients in sinus rhythm (SR), lone atrial fibrillation (AF), and AF with underlying mitral valve disease (MYD). Design: Case-control study. Patients: 118 patients with lone AF, MVD+AF, and SR. Main outcome measures: Collagen I, collagen Ill, and fibronectin protein expression measured by quantitative western blotting techniques and immunohistochemical methods. Results: Protein concentrations increased in patients with AF (all forms) compared with those in SR (all forms): collagen 1(1.15(0.11) v 0.45 (0.28), respectively; p = 0.002), collagen 111(0.74 (0.05) v 0.46 (0.11); p = 0.002, and fibronectin (0.88 (0.06) v 0.62 (0.1 3); p = 0.08). Especially, collagen I was similarly enhanced in both lone AF (1.49 (0.15) and MVD-i-AF (1.53 (0.16) compared with SR (0.56 (0.28); both p = 0.01). Collagen III was not significantly increased in lone AF but was significantly increased in AF combined with MYD (0.84 (0.07) both compared with SR (0.46 (0.11); p = 0.01). The concentration of fibronectin was not significantly increased in lone AF and MYD+AF (both compared with SR). Furthermore, there was a similar degree of enhanced collagen expression in paroxysmal AF and chronic AF. Conclusions: AF is associated with fibrosis. Forms of AF differ from each other in collagen III expression. However, there was no systematic difference in ECM expression between paroxysmal AF and chronic AF. Enhanced concentrations of ECM proteins may have a role in structural remodelling and the pathogenesis of AF as a result of separation of the cells by fibrotic depositions. [ABSTRACT FROM AUTHOR]

Evaluates the management of ischemic mitral regurgitation. Clinical evaluation; Functional ischemic mitral regurgitation following acute myocardial infarction; Functional ischemic mitral regurgitation in chronic cardiomyopathies; surgical treatment of functional ischemic mitral regurgitation; Surgical treatment of papillary muscle rupture.

Assesses the mitral regurgitation (MR), a valve lesion. Range of pathologies producing regurgitant mitral valve dysfunction; Diagnosis of MR; Normal mitral valve structure and function; Functional MR; Quantification of MR.

Discusses the degenerative mitral valve disease with emphasis on mitral valve prolapse. Effects of degenerative mitral valve disease; Histology patterns of degenerative mitral valve disease; Factors influencing severity; Diagnosis of mitral valve prolapse.

Objective: To evaluate the prevalence and correlates of left ventricular thrombosis in patients with acute myocardial infarction, and whether the occurrence of early mitral regurgitation has a protective effect against the formation of left ventricular thrombus. Design and setting: Multicentre clinical trial carried out in 47 Italian coronary care units. Patients and methods: 757 patients from the GISSI-3 echo substudy population with their first acute myocardial infarct were studied by echocardiography at 24-48 hours from symptom onset (S1), at discharge (S2), at six weeks (S3), and at six months (S4). The diagnosis of left ventricular thrombosis was based on the detection of an echo dense mass with defined margins visible throughout the cardiac cycle in at least two orthogonal views. Results: In 64 patients (8%), left ventricular thrombosis was detected in one or more examinations. Compared with the remaining 693 patients, subjects with left ventricular thrombosis were older (mean (SD) age: 64.6 (13.0) v59.8 (11.7) years, p < 0.005), and had larger infarcts (extent of wall motion asynergy: 40.9 (11.5)% v 24.9 (14)%, p < 0.001), greater depression of left ventricular ejection fraction at S1 (43.3 (6.9)% v48.1 (6.8)%, p < 0.001), and greater left ventricular volumes at S1 (end diastolic volume: 87 (22) v 78 (18) ml/m², p < 0.001; end systolic volume: 50 (17) v 41 (14) ml/m², p < 0.001). The prevalence of moderate to severe mitral regurgitation on colour Doppler at S1 was greater in patients who had left ventricular thrombosis at any time (10.2% v 4.2%, p < 0.05). On stepwise multiple logistic regression analysis the only independent variables related to the presence of left ventricular thrombosis were the extent of wall motion asynergy and anterior site of infarction. Conclusions: Left ventricular thrombosis is not reduced, and may even be increased, by early moderate to severe mitral regurgitation after acute myocardial infarction. The only... [ABSTRACT FROM AUTHOR]

Commissural fusion is now recognised as the principal pathology underlying mitral stenosis, and commissural splitting underlies successful interventional treatment. Although the technique of surgical commissurotomy was first described as early as 1948, percutaneous commissurotomy became a feasible option with the advent of the Inoue balloon in 1984. Percutaneous balloon mitral valvuloplasty is now the treatment of choice for many patients with symptomatic mitral stenosis. Numerous large series have reported excellent short, medium, and long term outcome with a low incidence of serious complications. Furthermore, randomized trials comparing balloon valvuloplasty with the surgical alternatives of open or closed commissurotomy have demonstrated equivalent outcome.

Mitral valve surgery has changed considerably in the past decades and is now indicated mostly for pure or predominant mitral regurgitation. This is the result of the regression of rheumatic disease, of the efficacy of mitral balloon valvuloplasty for mitral stenosis, and of the aging of the population with increasing degenerative or ischaemic disease causing mitral regurgitation. The timing of mitral surgery has remained one of the most difficult problems of clinical cardiology because symptoms can remain absent or minimal despite severe regurgitation caused by adaptive remodeling of left ventricle and atrium.

Background -- Abnormal flow patterns in the left atrium in atrial fibrillation or mitral stenosis are associated with an increased risk of thrombosis and systemic embolisation; the characteristics of normal atrial flow that avoid stasis have not been well defined. Objectives -- To present a three dimensional particle trace visualisation of normal left atrial flow in vivo, constructed from flow velocities in three dimensional space. Methods -- Particle trace visualisation of time resolved three dimensional magnetic resonance imaging velocity measurements was used to provide a display of intracardiac flow without the limitations of angle sensitivity or restriction to imaging planes. Global flow patterns of the left atrium were studied in 11 healthy volunteers. Results -- In all subjects vortical flow was observed in the atrium during systole and diastolic diastasis (mean (SD) duration of systolic vortex, 280 (77) ms; and of diastolic vortex, 256 (118) ms). The volume incorporated and recirculated within the vortices originated predominantly from the left pulmonary veins. Inflow from the right veins passed along the vortex periphery, constrained between the vortex and the atrial wall. Conclusions -- Global left atrial flow in the normal human heart comprises consistent patterns specific to the phase of the cardiac cycle. Separate paths of left and right pulmonary venous inflow and vortex formation may have beneficial effects in avoiding left atrial stasis in the normal subject in sinus rhythm. [ABSTRACT FROM AUTHOR]

Objective: To investigate the risk of outlet strut fracture (OSF) in Björk-Shiley convexo concave (BSCC) valves in relation to patients' clinical and valve characteristics.Design: A cohort of 2977 patients with 3325 valves with a follow up of 18 years.Setting: 38 cardiac implantation centres in the UK.Results: 56 OSF events were reported with 43 occurring in mitral and 13 in aortic valves. The overall OSF rate was 0.17%/year. No dominant clinical factor of risk was found, but multiple regression analysis identified age, body surface area, valve size, shop order fracture rate, and manufacturing period as risk factors for OSF. A 4% (95% confidence interval (CI) 2% to 6%) decrease in the risk of OSF was observed for each advancing year of age and a fivefold (95% CI 2 to 13) increase in risk for a 0.5 m(2) increase in body surface area. The association between the risk of OSF and valve size was not constant over time. Excess risks among 31 mm and 33 mm sizes (mainly mitral valves) decreased over time while that for 23 mm (almost all aortic valves) increased. The risk of OSF increased by 40% (95% CI 20% to 50%) for a unit increase in the fracture rate of other valves in the same batch. For valves manufactured during 1981 to 1984 the risk of OSF was 4 (95% CI 2 to 12) times greater than for valves manufactured before 1981.Conclusions: The OSF rates for 60 degrees BSCC valves observed in the UK are the highest among all monitored populations. The changing patterns of mitral and aortic valve OSF rates over time observed in this study have not been identified previously and highlight the need for continued monitoring of patients with the BSCC valve. [ABSTRACT FROM AUTHOR]

Transoesophageal echocardiography has greatly improved our ability to detect structural and regurgitant abnormalities associated with prosthetic mitral valves. [ABSTRACT FROM AUTHOR]

Editorial. Discusses the rationale, approach and interpretation in clinical practice of the quantitation of mitral regurgitation (MR), a valvar haemodynamic alteration. Importance of defining the degree of MR in the clinical decision making process; Benefits of development of mitral valve repair; Doppler echocardiography in patients with MR.

Objectives: Infants with symptomatic partial and transitional atrioventricular septal defect undergoing early surgical repair are thought to be at greater risk. However, the outcome and risk profile of this cohort of patients are poorly defined. The aim of this study was to investigate the outcome of symptomatic infants undergoing early repair and to identify risk factors which may predict mortality and reoperation.Methods: This multicentre study recruited 51 patients (24 female) in three tertiary centres between 2000 and 2015. The inclusion criteria were as follows: (1) partial and transitional atrioventricular septal defect, (2) heart failure unresponsive to treatment, (3) biventricular repair during the first year of life.Results: Median age at definitive surgery was 179 (range 0-357) days. Sixteen patients (31%) had unfavourable anatomy of the left atrioventricular valve: dysplastic (n=7), double orifice (n=3), severely deficient valve leaflets (n=1), hypoplastic left atrioventricular orifice and/or mural leaflet (n=3), short/poorly defined chords (n=2). There were three inhospital deaths (5.9%) after primary repair. Eleven patients (22%) were reoperated at a median interval of 40 days (4 days to 5.1 years) for severe left atrioventricular valve regurgitation and/or stenosis. One patient required mechanical replacement of the left atrioventricular valve. After median follow-up of 3.8 years (0.1-11.4 years), all patients were in New York Heart Association (NYHA) class I. In multivariable analysis, unfavourable anatomy of the left atrioventricular valve was the only risk factor associated with left atrioventricular valve reoperation.Conclusions: Although surgical repair is successful in the majority of the cases, patients with partial and transitional atrioventricular septal defect undergoing surgical repair during infancy experience significant morbidity and mortality. The reoperation rate is high with unfavourable left atrioventricular valve anatomy. [ABSTRACT FROM AUTHOR]

Objective: Unlike degenerative mitral valve (MV) disease, the advantages of valve repair procedure over replacement have been debated in rheumatic MV disease. This study aims to evaluate the impact of procedural types on long-term outcomes through analyses on a large data set from an endemic area of rheumatic disease.Methods: We evaluated 1731 consecutive patients (52.3±12.5 years; 1190 women) undergoing MV surgery for rheumatic MV disease between 1997 and 2015. Long-term survival and valve-related outcomes were compared between repair and replacement procedures. To adjust for selection bias, propensity score analyses were performed.Results: Patients undergoing repair were younger and had more predominant mitral regurgitation than mechanical and bioprosthetic replacement groups (61.6% vs 15.6% vs 24.4%; P<0.001). During follow-up (130.9±27.7 months), 283 patients (16.3%) died and 256 patients (14.8%) experienced valve-related complications. Propensity score matching yielded 188 pairs of repair and replacement patients that were well balanced for baseline covariates. In the matched cohort, there was no significant difference in the mortality risk between the repair and replacement groups (HR, 1.24; 95% CI 0.62 to 2.48). The risk of composite valve-related complications, however, was significantly lower in repair group (HR, 0.57; 95% CI 0.33 to 0.99) principally derived by a lower risk of haemorrhagic events (HR, 0.23; 95% CI 0.07 to 0.70). The incidence of reoperation was not significantly different between groups in the matched cohort (HR, 1.62; 95% CI 0.49 to 5.28).Conclusion: Valve repair in well-selected patients with severe rheumatic MV disease led to comparable survival, but superior valve-related outcomes compared with valve replacement surgery. [ABSTRACT FROM AUTHOR]

Objective: Although the factors associated with short-term survival from out-of-hospital cardiac arrest (OHCA) are well established, relatively little is known about the factors that influence long-term survival. In this study, we describe the 15-year survival outcomes of OHCA survivors and examine the influence of peri-arrest factors and 12-month outcomes on long-term survival.Methods: Survivors of OHCA between 2000 and 2014 identified from the Victorian Ambulance Cardiac Arrest Registry were linked with state-wide death records. Kaplan-Meier survival curves and Cox regression models were used to estimate long-term survival outcomes.Results: A total of 3449 patients were included with a mean survival duration of 11.9 (95% CI 11.7 to 12.1) years. The 1-year survival rate was 92.2% (95% CI 91.3% to 93.1%), while the 5, 10 and 15-year survival rates were 81.4% (95% CI 79.9% to 82.8%), 70.1% (95% CI 67.9% to 72.1%) and 62.3% (95% CI 58.9% to 65.5%), respectively. The standardised mortality rate of OHCA survivors was 5.6 times that of the standard Australian population in the first-year postarrest, but approached that of the standard population 5 years postarrest. Few peri-arrest factors were independently associated with long-term survival after discharge. Rather, transport to a percutaneous coronary intervention-capable hospital and discharge home from hospital were associated with longevity. Returning to work and favourable physical/functional recovery were associated with improved survival after 12 months.Conclusions: OHCA survivors experience relatively favourable long-term survival after discharge from hospital. While peri-arrest factors had little influence on long-term survival after hospital discharge, favourable recovery postdischarge was associated with improved long-term outcomes. [ABSTRACT FROM AUTHOR]

The bicuspid aortic valve (BAV) affects 1-2% of the population and may be associated with important valvular disease and an increased risk of aortic root and/or ascending aortic aneurysm and dissection. BAV aortic aneurysm and dissection occur earlier in life than when these disorders are associated with a tricuspid aortic valve (TAV). Alterations in the aortic media and differences in aortic elastic properties and wall stress also accompany BAV aortopathy. With appropriate follow-up and timely surgery, population studies have documented a survival rate for patients with BAV no different from age-matched controls. Guidelines have previously recommended prophylactic aortic surgery at a smaller aortic aneurysm size for patients with BAV compared with aneurysms in patients with a TAV. Recent guidelines have presented differing indications regarding the appropriate timing of prophylactic surgery for BAV aneurysms, giving the recommendation for surgery when the aortic root and/or ascending aortic exceeds 5.5 cm (unless certain factors are present), the same size for which TAV-associated aortic aneurysm surgery is recommended. We review the pathophysiology of BAV aortopathy, the clinical history of BAV ascending aortic disease, areas of uncertainty and make a case for a patient-centered, individualised decision regarding the optimal timing of aortic aneurysm surgery in BAV disease. [ABSTRACT FROM AUTHOR]

The author reflects on the association between mitral valve prolapse (MVP) and open-angle glaucoma (OAG). Topics include extracellular matrix (ECM) abnormalities due to increased activity of matrix metalloproteinases (MMPs) in interstitial cells of mitral valve, and iris and ciliary body, need for study on MVP cases with glaucoma and Marfan syndrome to understand the biological basis of the association and future research directions such as use of vasodilators for patients with OAG and MVP.

A quiz concerning the diagnosis and treatment of posterior mitral leaflet tear is presented.

The article presents a case study of 14-year-old girl presented with sudden onset abdominal pain and distension with bilious vomiting having Marfan syndrome. She had normal bowel sounds and was noted to have a typical marfanoid habitus with severe kyphoscoliosis, arachnodactyly and wrist sign. It informs that cardiogram showed mitral valve prolapse, tricuspid regurgitation and normal-sized aortic root.

The article presents a case study of a 23-year-old man who was referred for cardiac evaluation and diagnosed with isolated double-orifice mitral valve.

The article presents an obituary for former consultant in child psychiatry Sabina Jeannette Strich.

The article cites a research study focusing on the functional maturity of tricuspid and mitral valves in school children. The prevalence of valve regurgitation in healthy people has been previously examined by echocardiography. Pulmonary regurgitation or tricuspid regurgitation (TR) was common, mitral regurgitation (MR) was less common, and aortic regurgitation was generally undetectable. In this study, TR and MR were detected in 88 percent and 26 percent respectively, of school children. In the tricuspid valve, most regurgitations were classed as trivial. By contrast, in the mitral valve no signal was generally observed. Then, the prevalence decreased with severity. The overall severity of TR was significantly greater than that of MR.

The article discusses on the impact of stroke volume on mitral annular velocities derived from tissue Doppler imaging. Mitral annular velocities derived from pulsed tissue Doppler imaging were recently demonstrated to complement the analysis of systolic and diastolic left ventricular (LV) performance in different clinical settings. With changes in volume status, changes in the annular or myocardial tissue velocities have been noted to be less than the corresponding changes in mitral flow velocities.

Pulmonary hypertension frequently complicates mitral stenosis. Increased pulmonary artery pressure results from raised left atrial pressure, pulmonary arteriolar constriction, and obliterative changes in the pulmonary vascular bed, and usually responds to surgical relief of mitral stenosis. However, severe pulmonary hypertension may persist after surgical treatment of mitral stenosis. We describe a patient whose severe pulmonary hypertension following mitral valve replacement was treated successfully with continuous intravenous epoprostenol. [ABSTRACT FROM AUTHOR]

This article focuses on a study related to initial experience with three dimensional real time 3D color flow Doppler for assessment of mitral regurgitation. Real time 3D color Doppler provides a novel approach to qualitative and quantitative flow assessment. 50 patients underwent 2D and 3D color Doppler imaging at the mitral valve and left ventricular outflow tract. 3D colour Doppler may provide a swift and accurate modality for quantifying mitral regurgitation, particularly in the presence of eccentric jets.

Editorial. Comments on key issues concerning calcific valve disease, which represents a disease spectrum ranging from mild irregular valve thickening to severe valve obstruction. Aortic stenosis; Clinical implications; Significance to cardiology.

Examines the case of a patient with mitral stenosis who died of massive hematemesis resulting from atrio-esophageal fistula. Factors affecting the development of fistula; Common complications of mitral valve disease; Frequency of cases of fistula as a complication of mitral valve disease.